Provider Demographics
NPI:1922127448
Name:ROBERTO, FRED JAMES (DC)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:JAMES
Last Name:ROBERTO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5041 DALLAS HWY
Mailing Address - Street 2:SUITE 500
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-6458
Mailing Address - Country:US
Mailing Address - Phone:770-919-7171
Mailing Address - Fax:770-218-0341
Practice Address - Street 1:5041 DALLAS HWY
Practice Address - Street 2:SUITE 500
Practice Address - City:POWDER SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30127-6458
Practice Address - Country:US
Practice Address - Phone:770-919-7171
Practice Address - Fax:770-218-0341
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR005581111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA637180OtherBLUE CROSS BLUE SHIELD
GA35ZCFVKMedicare ID - Type Unspecified
GA637180OtherBLUE CROSS BLUE SHIELD